Follow the steps to fill out the IA DHS 470-0254 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by indicating the reason for your application by checking the appropriate box—either 'New enrollee in Medicaid' or 'Changing to a new Tax Identification Number'.
3. Fill in Section A, Organizational Data with your practice's legal name, Tax Identification Number, and other required information, ensuring all details align with your tax documents.
4. In Section A, provide your Primary Organizational National Provider Identifier (NPI) and the physical location of your practice, including street address, city, state, and zip code.
5. Complete all subsections under Section A, including your contact information and business type, being careful to check all relevant boxes regarding your practice's involvement in specific programs like the 340B Drug Pricing Program.
6. Proceed to Section B, Identifying Information, where you will be asked to provide characteristics of the individual or group being enrolled, including type code, licensee name, Tax ID, and social security number.
7. For each individual linked to the organization, input additional service location addresses and contact information as needed.
8. In Section C, Additional Information (for individual providers only), fill out questions regarding your credentials such as training, licenses, and any additional pertinent details.
9. Review your entire form for accuracy. Ensure all fields are filled correctly, including any optional comments or attachments required.
10. Once you have verified all information, save the document, then download, print, or share the completed form as necessary.

Complete your forms online to facilitate a smooth application process.